Provider Demographics
NPI:1134136393
Name:ANDERSON, LISA L (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 ST. CLAIRE PLACE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21666
Mailing Address - Country:US
Mailing Address - Phone:410-643-3795
Mailing Address - Fax:410-643-3797
Practice Address - Street 1:200 ST. CLAIRE PLACE
Practice Address - Street 2:SUITE 150
Practice Address - City:STEVENSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21666
Practice Address - Country:US
Practice Address - Phone:410-643-3795
Practice Address - Fax:410-643-3797
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0065976207N00000X
LA025648174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD023155000Medicaid
LA1045993Medicaid
I36057Medicare UPIN
MD188358ZFQEMedicare Oscar/Certification
MD188358ZFQEMedicare Oscar/Certification